The Effects of Diet Intake on Encopresis.
he best single, comprehensive, and manageable resource (49 pages) I know of for information on disorders of the gastrointestinal tract is a Harvard Health Letter Special Report entitled The Sensitive Gut first published in 1996 and last revised in 2012. Another valuable source for information is the International Foundation of Functional Gastrointestinal Disorders (IFFGD). The IFFGD is a nonprofit education and research organization founded in 1991. IFFGD addresses the issues surrounding life with gastrointestinal (GI) functional and motility disorders and increases the awareness about these disorders among the general public, researchers, and the clinical care community. Their website lists information and fact sheets, which can be purchased for learning about a variety of problems and interventions unique to the GI tract.
Fiber in the Diet:
Dietary fiber tends to increase the bulk of the stool, softens it, and likely enhances motility reducing over all transit time (12-72 hours). The current recommendation for adults is 20-35 gm per day, far above that consumed by most Americans. The requirements for children, ages 3-18, are less than for adults. The American Dietetic Association reports a formula for determining recommended fiber intake–a child’s age plus five equals the grams of dietary fiber he or she should eat daily. There are two basic forms of dietary fiber, insoluble and soluble. Insoluble fiber does not dissolve or gel in water and is poorly fermented. Insoluble fiber adds bulk to the stool directly. Soluble fiber dissolves in water, becomes a soft gel, and is readily fermented. It includes pectin in fruit, which retains water adding to bulk and softening. Colon bacteria action on soluble fiber creates gas and helps to increase fecal mass. Insoluble fiber would include wheat bran, corn bran, whole grains, dried beans and peas, popcorn, seeds and nuts, most fruits and veggies, especially carrots, white potatoes, artichokes, broccoli, leeks, and parsnips. Soluble fiber includes psyllium, oat bran, whole oats, rice bran, dried beans, chick peas, black-eyed peas, lentils and virtually all fruits and vegetables, but especially citrus, apples, pears, sweet potatoes, carrots, okra, cauliflower, and corn. Some high fiber substances may contain both soluble and insoluble fibers.
CAUTION: Parents and many physicians tend to over-exaggerate the importance of fiber. There is the very real possibility that it may promote too much stool which the child is not able to evacuate completely with required sits. This may be especially true for children who are resistant to sitting on the toilet stool and have retentive encopresis with an enlarged colon. The Soiling Solutions protocol assures daily, more complete evacuations which makes diet a much less significant factor. This assures that older, more dried out, darker, or formented (rotten) stool is eliminated leaving fresher brownish stool behind. Drinking sufficient fluids may be even more relevant. Soluble fiber may be more helpful because it forms a more gelatinous mass and retains more water as opposed to insoluble fiber where the stool can become more brick-like or peanut butter-like. Commercially available soluble fiber supplements would include Pectin and Citrucel which is preferred by the week-long bowel management out-patient program at the Colorectal Center at the Cincinnati Childrens Hospital. DrC.
Probiotics in the Diet:
Our digestive tracts are populated by over 400 varieties of bacteria that assist in digestion. Probiotics are introduced into the gut by dietary supplements and are regulated as foods, not drugs. Their main use has been to repopulate the GI tract following the use of antibiotics and accompanying diarrhea. They show some promise for managing Irritable Bowel Syndrome (IBS) in adults. They are a popular topic on lay encopresis forums. Lactic acid bacteria are found as live cultures in Yogurt which is a popular food source, but they can also be purchased as capsules in most pharmacies and grocery stores. Their value for constipation and encopresis has not been scientifically demonstrated. Parents out of their frustration with constipation and encopresis often experiment with them and offer anecdotal positive observations in their constant search for helpful diet aids.
Stool Softeners in the Diet:
These commercial substances mix in with the feces and soften their consistency. The leading, most prescribed stool softener with the fewest side effects today is Miralax (Polyethylene Glycol or PEG) in the USA which is called Movicol in other countries. Lactulose was most commonly used before Miralax or Movicol and is still widely available. It is a sugar-based product. Mineral oil (MO) was very commonly used, but is generally discouraged today because it reduces absorption of fat-soluble vitamins and can induce lung damage if accidentally inhaled. Another problem is that it remains as a liquid in the GI tract and the child will tend to have more of a problem with leakage and difficulty telling if he/she is about to pass gas or have an accident. An emulsified form of mineral oil such as Kondremul is more easily tolerated and mixes in much better with the stool as a softener, but the same cautions remain for vitamin deficiency or inhalation by an upset child. Docusate Sodium (Colace, Dialose, Surfak, others) is generally safe for long-term use, but should not be used with mineral oil. The problem with Docusate Sodium is that it has a horrible taste and if you get it in solid form (a gel cap) some kids have trouble swallowing it as they might for any pill. The substances above are all available “off the shelf”.
Aside: Always consult with a physician when utilizing even “off the shelf” medications for an extended period. Read and check about cautions and possible adverse interactions with any medication. In general they appear to be quite safe.
Osmotic or Hypermolar Agents (e.g., MOM, Miralax)
These are mostly salts or carbohydrates (Miralax being an exception as a long chain carbon molecule) taken orally that promote the transport of bodily fluids across the gastrointestinal membrane from the surrounding tissues into the colon by the process of osmosis. They also act as softening agents and in high doses promote a clean out of the colon. Some have been mentioned above. They include Milk of Magnesia (MOM), citrate of magnesium, Epsom salts, lactulose, and sorbitol. The Harvard Health Letter special report on the sensitive gut notes that the latter is less expensive than lactulose and equally effective. Encouraging a child to drink lots of water or sports drinks is advisable with these agents to prevent dehydration or altered electrolyte levels. Miralax (Polyethylene Glycol or PEG) has become dominant with the current dominant practice of a top down treatment for encopresis. It can be difficult to adjust the dosage for stool that is not overly soft. A liquified stool creates problems with leakage and may hinder achieving control. The Colorectal Center at the Cincinnati Children’s Hospital discourages Miralax usage with chronic encopresis because it does not offer a mass for stimulant laxatives like Senna or Bisacodyl to push against. The true issue for chronic encopresis may not be stool hardness, but rather very compromised and weakened peristalsis or pushing contractions because of an enlarged and weakened colon. This is an unfortunate consequence of allowing encopresis to go on for too long because of hope and repeated medical advice that the child “…will grow out of it.”
Top down use of stimulant (irritative) laxatives bathing the entire GI tract can lead to dependency, lesser effectiveness with daily use, and they can cause changes in the bowel over extended periods of time. However their usage is coming to be more frequent with less concern over their long term effects which may not be as concerning as originally thought. There is increasing awareness that the continuation of encopresis can in itself can cause considerable long term emotional and physical damage. Living with encopresis is really intolerable and many providers who do not have to live with it truly do not understand. These agents include Bisacodyl and Senna (a vegetable laxative). Senna can be dosed by squares in a divided chocolate bar The most common brand of Senna is Ex-lax, but a cheaper store brand version can be found on the shelf next to it. Or, it can be dosed as a liquid (e.g., Senokot). We will see in the next section that starting the GI engine from the top is much more unpredictable in terms of timing (6-12 hours) before strong elimination urges. Starting up the voiding reflex from the “bottom” is much more predictable and timely. Cultural sensitivities and the common practice of oral medications for most ills make the use of oral laxatives so much more acceptable. Some leading pediatric gastroenterologists pointedly refer to oral laxatives or stool softeners as the “gentle” approach. It was very unfortunate that back in the late 1970′s and early 1980′s a couple of very significant pediatric medical publications referred to the use of suppositories and enemas as “anal assault” and “anal stamp.”
Suppositories and Enemas as “Bottom Medicine”:
Enemas are liquids introduced rectally to stimulate an almost immediate voiding reflex and will be described more fully in the next paragraph. Suppositories are solids introduced by the same route to promote voiding. A mild suppository is glycerin in a solid stick-like or bullet form. Glycerin in its natural form is a liquid, but it can be mixed with a wax much like chocolate can be to make it solid and melt less quickly. It mainly provides for adding bulk, lubrication, and moisture retention to stimulate and ease evacuation. It is a common ingredient in shaving lotions and K-Y lubricating cream so it is very safe and non-irritating in general. Bisacodyl can be used as a suppository and is a more powerful voiding agent. Dulcolax is a common brand. An even more powerful and stimulative bisacodyl suppository brand is the “Magic Bullet” which is water-based. It melts easily upon insertion and is absorbed rapidly. The term “liquid suppository” is an oxymoron, but has become commonplace because marketing types found that the term suppository had a less negative impression than an enema for sales of very small enema liquid squeeze bottles. Liquid glycerin is much more stimulative and is sold as a “liquid suppository” for infants (Pedialax) and adults. Bisacodyl is also available in the “liquid suppository” bottle form. The rectal route is the least favorite choice of parents and children. It is viewed as a last resort because of the emotional and physical conflicts that almost inevitably result with very anxious children and frightened, scared parents. Encopretic children almost by definition do not want to use the anal passage for anything going out much less anything going in! Curiously, this very attitude probably leads to the necessity of having to use enemas more often than is really necessary for clean outs because these children are very susceptible to holding stool and getting backed up over and over. Backed up stool tends to dry out and harden which can cause an obstruction or leakage of stool around the blockage, often leaving an enema as the only solution for adequate emptying.
An enema is simply the procedure of adding fluid to the rectum and sigmoid colon, which promotes bowel contractions. It is a very powerful and immediate unconditioned stimulus leading to an unconditioned response of bowel evacuation. Most of us have learned more subtle conditioned stimuli cues for voiding. For example, the gastrocolic reflex after breakfast with coffee. Few children can successfully resist voiding with an enema. I suspect that for these children oral laxatives lead to very tiring battles and confusion within their bodies in attempting to resist voiding contraction cues for days at a time!!! The success of the Soiling Solutions(R) (SS) protocol relies on the much more predictable action of the rectal route for promoting rapid conditioning of successful pooping on the toilet with the immediate relief experienced by the child. However, simply repeating enemas day after day is not a rational program. SS is carefully designed to lead the child to becoming self-sufficient and independent. A daily “Power Hour” with carefully designed steps spelled out in the Clean Kid Manual(C) (CKM) is necessary to enable a transition to the child’s independence.